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Many Black, HIV-Infected Women in Mississippi Are Lost to Care After Giving Birth
An Interview With Aadia Rana, M.D.

By Bonnie Goldman

October 25, 2008

There's nothing like hearing the results of studies directly from those who actually conducted the research. In this interview, you'll meet one of these impressive HIV researchers and read her explanation of the study she presented at ICAAC/IDSA 2008.

My name's Aadia Rana. I'm with Warren Alpert Medical School at Brown University. I worked on a descriptive study of HIV-infected pregnant women in Mississippi.1 The motivation behind the study was the fact that CDC [U.S. Centers for Disease Control and Prevention] data indicates that HIV infection is in African-American women who are of reproductive age in the South. More than 80% of the women who are HIV infected are of reproductive age.

Aadia Rana, M.D.
Aadia Rana, M.D.
We have this collaboration with the folks down in Mississippi at the University of Mississippi Medical Center. We felt that there wasn't a lot of information on these women. I did a chart review of all pregnancies that were seen at the University of Mississippi Medical Center Perinatal HIV Service from 1999 to 2006, and abstracted HIV and sociodemographic data.

The main points of our study were: These women were young -- they were 25 and were mainly African American. There were low socioeconomic factors. We found that there were comorbidities, including high rates of sexually transmitted diseases [STDs]. Almost one quarter of the women had STDs, and almost 15% had associated substance abuse.

The main thing we also wanted to focus on was looking at whether these women follow up with their HIV provider after they deliver. The focus of most of the literature in HIV medicine has been on whether there's been decreasing mother-to-child transmission and we've done fabulous on that. But the question remains, what happens to the woman after the baby is born and the baby is negative?

Very disappointingly, we found that almost half of the women either had no or only one visit with an HIV provider after their delivery. The standard of care set up by primary care guidelines for an HIV-infected person is at least one visit every three to four months. This is quite abysmal.

What we're going to do next now is look at predictors of these follow-up rates. We're also going to start a prospective study where we enroll these women as they engage in care with a perinatal HIV service, so that we can develop targeted interventions to improve their follow-up rates.

Can you tell me a little bit about the clinical characteristics and the baseline demographics?

Absolutely. The women were generally young. Median age at presentation was 25. The overwhelming majority, almost 99% were infected through heterosexual transmission. They were predominately African American -- 89%. The majority of the women had a high school education, but not much after that. In terms of employment, the majority of these women at the time -- of the pregnancy at least -- were unemployed. A third of these women live within the municipality of Jackson, probably close to 50% within the five counties surrounding Jackson.

The CD4+ cell count at presentation for all of these women was about 350 cells/mm3, which is within the range of the recommendations for starting antiretroviral therapy. The majority of these women were started on antiretroviral therapy to decrease mother-to-child transmission, but of the number of women that I have, only 61% had what's considered an undetectable plasma viral load of less than 400 copies/mL.

They had been diagnosed with HIV for only about two years on average. The majority of these women also presented after second trimester, which is rather late -- 2% actually presented at delivery. A third of these women were diagnosed during the pregnancy, prenatal diagnosis. We're not sure whether that's a reflection of the fact that they have opt-out testing in Mississippi during pregnancy, which they've had for a long time, and/or the fact that there's poor community-based testing in Mississippi. So these women are finding out only when they engage with care.

Smoking and substance abuse are certainly significant comorbidities in these women. Almost a quarter had gonorrhea or chlamydia diagnosed during their pregnancy. A little over a quarter had a history of sexually transmitted illness.

The most interesting thing we found was that almost 70% of the women -- this is in the 161 women that I could collect the data on -- had bilateral tubal ligation as a postpartum contraception plan, which I thought was relatively high, but might be a reflection of the fact that most of these women were multiparous, so they were no longer interested in having children.

Do you think that it's generally offered in this hospital? Because it is an unusually high rate.

It is high, though I would have to compare it to that of the general population, which I don't know the rate for. I don't know if bilateral tubal ligation is encouraged or if it's a cultural thing reflective of race or education level.

Were most of these women on Medicaid?

Almost overwhelmingly, the majority are on Medicaid. The thing is, I couldn't ascertain whether they were uninsured before, because all women during pregnancy are on Medicaid if they have no insurance. They are given Medicaid during the duration of their pregnancy. So I didn't tease out whether they had been on Medicaid prior or they were just uninsured and were on Medicaid during their pregnancy.

Does this hospital have case management for HIV-infected women?

During the pregnancy, absolutely. They actually have a pretty involved infrastructure for these women during their pregnancy. It's after pregnancy that it's not as involved. The focus is really on decreasing mother-to-child transmission.

So they don't have transportation programs for the women or other stuff afterwards?

Afterwards, they do. It's certainly up to the women to decide to engage, but the programs are not as aggressive. There's not as much energy focused on it. They've been flat-funded for the last five years or so, even though the numbers have been going up and up and up.

Turner Overton did a study2 that he presented last year with a longer follow-up in which there were actually deaths in the women, two or three years after they had a baby.

After they had the baby, yes. Since I only did one year, that's sort of censored data for me, but yes, there were at least eight deaths among the women within three years of their pregnancy.

It's a really tragic situation.

It is a very tragic situation.

And nobody's paying attention to it.

Hopefully they will now.

Thank you very much.

This transcript has been lightly edited for clarity.


References

  1. Rana AI, Gilani F, Beckwith C, Flanigan T, Nash B. Pregnancies among HIV-infected women in Mississippi. In: Program and abstracts of the 48th Annual ICAAC/IDSA 46th Annual Meeting; October 25-28, 2008; Washington, D.C. Abstract H-453.
  2. Onen NF, Nurutdinova D, Sungkanuparph S, Mondy K, Overton ET. HIV treatment interruption after pregnancy. Are we treating women SMARTly? In: Program and abstracts of the 45th Annual Meeting of the Infectious Diseases Society of America; October 4-7, 2007; San Diego, Calif. Abstract 937.
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